Treating Generalized and Social Anxiety Disorders with Individuals who are Neurodivergent with a Positive Systems Approach

Anxiety disorders are notably prevalent among neurodivergent individuals and those with developmental disabilities, presenting unique challenges in diagnosis and treatment. Traditional therapeutic approaches often fall short in addressing the specific needs of this population. Dr. Bob Carey, a clinical psychologist with over 35 years of experience in developmental disabilities and dual diagnosis, developed the Positive Systems Approach (PSA) to offer a more effective framework for managing disruptive behaviours and associated anxiety in these individuals.

Prevalence and Types of Anxiety Disorders in Neurodivergent Populations

Research indicates that anxiety disorders are among the most common co-occurring conditions in individuals with neurodevelopmental disorders. A meta-analysis reported that approximately 39.6% of children with Autism Spectrum Disorder (ASD) experience at least one anxiety disorder, with specific phobias (29.8%), obsessive-compulsive disorder (17.4%), and social anxiety disorder (16.6%) being the most prevalent (pmc.ncbi.nlm.nih.gov).  Similarly, studies have found that 51.6% of adolescents with Fragile X Syndrome (FXS) and 50.0% of those with ASD meet criteria for an anxiety disorder (pmc.ncbi.nlm.nih.gov).  In adults, the prevalence remains significant. Anxiety disorders were diagnosed in 20.1% of adults with ASD compared to 8.7% in the general population, indicating a substantially higher risk in the neurodivergent community (link.springer.com).  These statistics underscore the critical need for tailored interventions that address the unique manifestations of anxiety in neurodivergent individuals.

Challenges with Traditional Treatments

Traditional anxiety treatments, such as Cognitive Behavioural Therapy (CBT) and pharmacological interventions, often assume a level of cognitive and communicative function that may not align with the abilities of individuals with developmental disabilities. Moreover, these approaches may not account for the sensory sensitivities and atypical social perceptions common in neurodivergent populations. Consequently, there is a pressing need for alternative strategies that are both accessible and effective for these individuals.

The Positive Systems Approach (PSA)

Dr. Bob Carey, a registered clinical psychologist, along with Terry Kirkpatrick, have dedicated their careers to supporting individuals with developmental disabilities and dual diagnoses. Drawing from their extensive experience, each with over 35 years of working in this field, they wrote about the importance of  using a comprehensive framework that integrates principles from systems theory, applied behaviour analysis, psychological therapies and other approaches. This Positive Systems Approach is a strengths-based, person-centered approach that focuses on promoting positive outcomes and enhancing the quality of life for individuals exhibiting complex and challenging behaviours (amazon.com:  “Managing Disruptive Behaviours with a Positive Systems Approach”). 

Core Principles of PSA

1. Holistic Assessment: Understanding the individual's history, environment, and personal experiences to identify factors contributing to anxiety and disruptive behaviours.

2. Strengths-Based Planning: Leveraging the individual's abilities and interests to develop personalized support plans that foster engagement and reduce anxiety.

3. Environmental Modification: Adjusting the physical and social environment to minimize triggers and create a supportive setting conducive to positive behaviours.

4. Skill Development: Teaching coping strategies and social skills that empower individuals to manage anxiety and navigate social interactions more effectively.

5. Collaborative Support: Engaging families, caregivers, and professionals in a unified approach to ensure consistency and reinforcement across all areas of the individual's life.

Implementing PSA in Managing Anxiety Disorders

The application of PSA in addressing anxiety involves several key steps:

• Comprehensive Evaluation: Assessing the individual's specific anxiety triggers, sensory sensitivities, and communication preferences to inform tailored interventions.

• Personalized Intervention Strategies: Developing interventions that align with the individual's strengths and interests, such as incorporating preferred activities to ease anxiety-provoking situations.

• Consistent Monitoring and Adaptation: Regularly reviewing the effectiveness of interventions and making necessary adjustments to accommodate evolving needs and circumstances.

Generalized Anxiety and Social Anxiety Disorders:

Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SAD) can present differently in neurodivergent individuals compared to neurotypical individuals due to differences in cognitive processing, sensory sensitivities, and social communication challenges. Below is an overview of how these disorders commonly manifest in neurodivergent individuals, particularly those with Autism Spectrum Disorder (ASD), ADHD, or other developmental disabilities.

Generalized Anxiety Disorder (GAD) in Neurodivergent Individuals

GAD is characterized by excessive, persistent worry about various aspects of daily life. In neurodivergent individuals, this worry is often amplified by difficulties with processing uncertainty, sensory sensitivities, and social challenges.

Common Presentations:

1. Intolerance of Uncertainty:

   • Strong need for predictability and routine; extreme distress when routines are disrupted.

   • Persistent “what if” questions about hypothetical negative outcomes.

2. Sensory-Related Anxiety:

   • Anxiety triggered by overwhelming sensory stimuli, such as loud noises, bright lights, or certain textures.

   • Avoidance of specific environments (e.g., crowded places, classrooms, or shopping malls) due to sensory overload.

3. Cognitive Rigidity and Overthinking:

   • Repetitive thoughts about potential failures, misunderstandings, or past mistakes.

   • Hyper-focus on small details, leading to excessive worry about perfectionism and performance.

4. Somatic Symptoms:

   • Frequent stomach-aches, headaches, or nausea due to chronic stress.

   • Muscle tension, restlessness, and difficulty sleeping.

5. Difficulty Transitioning Between Tasks:

   • Anxiety about shifting from one activity to another, especially if the next task is uncertain or unstructured.

   • May become fixated on certain interests or tasks as a coping mechanism.

6. Emotional Dysregulation:

   • Outbursts, shutdowns, or meltdowns in response to overwhelming anxiety.

   • Difficulty self-soothing without external supports (e.g., stimming behaviours like rocking or hand-flapping).

Social Anxiety Disorder (SAD) in Neurodivergent Individuals

SAD involves intense fear of social interactions, particularly in situations where the individual fears embarrassment, judgment, or rejection. In neurodivergent individuals, SAD is often intertwined with social communication challenges and difficulties interpreting social cues.

Common Presentations:

1. Social Avoidance and Withdrawal:

   • Avoids group activities, social gatherings, or new interactions due to fear of being judged or making mistakes.

   • Prefers online or text-based communication over face-to-face interactions.

2. Difficulty Initiating or Maintaining Conversations:

   • Struggles with small talk, eye contact, and nonverbal communication cues.

   • Fear of saying something “wrong” leads to silence or excessive rehearsing of responses.

3. Masking and Exhaustion:

   • Tries to mimic neurotypical social behaviour to fit in, leading to extreme mental and emotional fatigue.

   • May experience burnout after prolonged social interactions.

4. Extreme Self-Consciousness and Hyperawareness:

   • Constantly analyzing their own behaviour and worrying about how others perceive them.

   • Over-apologizing or excessively replaying past social interactions in their mind.

5. Panic Symptoms in Social Situations:

   • Rapid heartbeat, sweating, nausea, or even full-blown panic attacks when faced with social interactions.

   • Feeling frozen, dissociated, or unable to respond in conversations.

6. Relying on Special Interests as a Social Buffer:

   • More comfortable talking about niche topics of interest but struggles with broader social interactions.

   • May monopolize conversations with their special interests due to difficulty gauging social cues.

Overlap Between GAD and SAD in Neurodivergent Individuals

Since neurodivergent individuals often experience heightened anxiety overall, GAD and SAD frequently co-occur. This can result in: Persistent worry about upcoming social situations (GAD component) combined with avoidance of those situations (SAD component).

• Ritualized behaviours or stimming to cope with excessive worry.

• Meltdowns or shutdowns when social or academic expectations become overwhelming.

Why Traditional Treatments Often Fall Short

• CBT Assumptions of Rational Thought: Many cognitive-behavioural therapy (CBT) techniques require self-reflection and cognitive restructuring, which may be difficult for individuals with alexithymia (difficulty identifying emotions).

• Exposure Therapy Risks: Gradual exposure to feared situations must be done cautiously, as forcing interactions too quickly can lead to further avoidance or trauma.

• Medication Sensitivities: Some neurodivergent individuals are more sensitive to side effects of anti-anxiety medications, necessitating careful adjustments.

Interventions like the Positive Systems Approach (PSA) provide structured, strengths-based strategies that focus on reducing anxiety through predictability, skill-building, and environmental supports rather than relying solely on traditional therapeutic models.  Following are some practical recommendations that are often incorporated into a PSA approach in supporting individuals with GAD and SAD:

Managing Generalized Anxiety Disorder (GAD)

1. Establish Predictability & Routine

• Use visual schedules, checklists, and timers to create a clear structure.

• Prepare for changes in advance with social stories or "what to expect" explanations.

• Provide transition warnings (e.g., "In 10 minutes, we will stop working on this and start our next activity").

2. Reduce Cognitive Overload

• Break tasks into small, manageable steps to prevent overwhelm.

• Allow extra processing time before expecting responses.

• Use alternative communication methods (e.g., written instructions instead of verbal).

3. Teach Emotional Regulation Strategies

• Help identify emotions using mood charts or emotion thermometers.

• Introduce self-regulation techniques like deep breathing, progressive muscle relaxation, or sensory-based strategies (e.g., fidget toys, weighted blankets).

• Encourage predictable calming routines (e.g., listening to familiar music before stressful tasks).

4. Encourage Special Interests as a Coping Mechanism

• Integrate preferred activities into daily routines to serve as a natural anxiety reducer.

• Use interests as a bridge for skill-building (e.g., role-playing anxiety-inducing situations within an area of interest).

5. Limit Unnecessary Stressors

• Adjust the environment to minimize triggers (e.g., reducing noise, allowing flexible seating).

• Identify and remove unrealistic academic or social expectations that add undue stress.

Managing Social Anxiety Disorder (SAD)

1. Build Social Confidence Through Safe, Low-Stress Interactions

• Start with one-on-one conversations before progressing to larger groups.

• Encourage structured social settings (e.g., shared-interest clubs) where conversation feels more natural.

• Role-play common social situations using scripts or guided practice.

2. Provide Alternative Socialization Options

• Allow for non-verbal social engagement, such as shared activities where talking isn’t required.

• Use text or online communication as a stepping stone to in-person interactions.

• Encourage parallel play or side-by-side activities, where interaction happens naturally.

3. Support Social Self-Awareness Without Creating Pressure

• Avoid forcing eye contact—instead, teach natural alternatives like looking at someone's forehead.

• Reframe social misunderstandings with gentle coaching, rather than criticism.

• Celebrate small social successes without pushing too hard for change.

4. Teach Coping Strategies for Social Situations

• Encourage self-soothing techniques before social interactions (e.g., breathing exercises).

• Develop exit strategies for overwhelming situations (e.g., “If I need a break, I can step outside for 5 minutes”).

• Normalize using scripts or conversation starters to reduce stress.

5. Address Social Anxiety in Academic or Work Settings

• Provide alternative participation options (e.g., submitting written responses instead of speaking in class).

• Assign structured roles in group work that align with the individual’s strengths.

• Allow mentors or peer buddies to help ease social engagement.

Case Study: Applying the Positive Systems Approach (PSA) to a Neurodivergent Individual with Generalized Anxiety Disorder and Social Anxiety Disorder

Background: Ethan is a 19-year-old neurodivergent individual diagnosed with Autism Spectrum Disorder (ASD), Generalized Anxiety Disorder (GAD), and Social Anxiety Disorder (SAD). He lives with his parents and attends a community college part-time. Ethan experiences excessive worry about daily activities, including schoolwork, social interactions, and unexpected changes in routine. His social anxiety manifests as extreme discomfort in group settings, avoidance of eye contact, and difficulty initiating conversations.

Despite his intelligence and passion for technology, Ethan’s anxiety significantly impairs his ability to engage in academic and social settings. He has a history of school refusal and has struggled with making and maintaining friendships. His parents sought intervention due to his increasing isolation and frequent panic episodes before social or academic events.

Assessment and Initial Observations: A comprehensive assessment was conducted using the Positive Systems Approach (PSA). The evaluation included:

·       Environmental Analysis: Identifying stressors in Ethan’s home, academic, and social settings.

·       Behavioural Tracking: Documenting triggers, frequency, and intensity of anxiety-related behaviours.

·       Strengths-Based Assessment: Identifying Ethan’s interests, coping mechanisms, and supportive relationships.

Findings from the assessment revealed:

1.     Ethan’s anxiety was exacerbated by unpredictable changes, sensory overload, and unfamiliar social environments.

2.     He displayed avoidance behaviours, such as skipping classes, to reduce his exposure to stressors.

3.     His strengths included strong problem-solving skills, deep interest in computer programming, and an ability to focus intensely on tasks he found engaging.

Intervention Plan Using PSA: Based on the assessment, a structured intervention plan was developed using the core principles of PSA:

1.     Holistic Support and Environmental Modifications:

o   Predictability: A structured daily schedule with visual supports (e.g., planners, timers) was introduced to help Ethan feel more in control.

o   Sensory Adjustments: Noise-canceling headphones and designated quiet spaces at home and school provided relief from sensory overload.

o   Gradual Exposure: Ethan was introduced to social situations incrementally, starting with one-on-one interactions before progressing to small groups.

2.     Skill Development and Strengths-Based Engagement:

o   Cognitive Reframing: Ethan practiced identifying negative thoughts and replacing them with neutral or positive alternatives using guided exercises.

o   Social Coaching: Role-playing and scripting exercises helped him navigate conversations and develop social confidence.

o   Strengths Integration: He was encouraged to participate in technology clubs where he could engage in social interactions centered around his interests.

3.     Collaborative Support and Caregiver Training:

o   His family received training on PSA principles, emphasizing positive reinforcement and structured communication strategies.

o   College instructors were informed about Ethan’s needs and provided accommodations, such as extended deadlines and alternative participation methods (e.g., written discussion contributions instead of verbal presentations).

4.     Consistent Monitoring and Adjustments:

o   Weekly check-ins assessed Ethan’s progress, and modifications were made as needed.

o   A social mentor was introduced to support Ethan’s integration into peer activities.

Outcomes: After six months of intervention, Ethan demonstrated significant improvements:

·       He attended college more consistently and completed coursework with reduced anxiety.

·       He engaged in structured social interactions, including attending a programming club where he contributed to group projects.

·       He developed coping strategies, such as using breathing exercises and cognitive reframing techniques during anxiety-provoking situations.

·       Panic episodes decreased in frequency and intensity.

Conclusion: 

The Positive Systems Approach provided Ethan with a structured, strengths-based framework that addressed his specific needs. By integrating environmental modifications, skill development, and collaborative support, PSA helped Ethan navigate anxiety challenges while fostering independence and confidence. His progress highlights the efficacy of PSA in enhancing the well-being of neurodivergent individuals with co-occurring anxiety disorders.  Neurodivergent individuals with GAD or SAD thrive when anxiety management strategies are tailored to their specific sensory, cognitive, and social needs. Using structured support systems like the Positive Systems Approach (PSA) ensures interventions are:

✅ Predictable (reducing anxiety about the unknown),

✅ Strengths-Based (leveraging individual interests and abilities), and

✅ Collaborative (engaging caregivers, educators, and therapists for consistency).